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Asthma Today

PATIENT INFORMATION SERIES | CONFERENCE EDITION

With this resource, you will learn: The definition of asthma The history of asthma Asthma triggers How asthma is diagnosed Treatments for asthma New research on asthma Opportunities to learn more

More than 26 million people in the United States—about 8 percent of the population—have asthma, an increase of 5 million people since 2001. U.S. government agencies estimate that asthma costs the nation $56 billion every year in medical costs, lost school days and workdays, and early deaths.

Public and private institutions have invest-ed billions of dollars on research to expand what we know about the causes of asthma and best treatments for those who have the disease. The best of this research is presented annually at the American Thoracic Society

(ATS) International Conference. Asthma Today, part of the ATS Patient Information Series, puts the latest research about asthma presented at the 2015 conference in the

FACTS & FIGURES

ATS PATIENT RESOURCES FOR ASTHMA: thoracic.org/patients/patient-resources/topic-specific/asthma.php 1

American Thoracic Society

Supported by a generous donation from TEVA.

1 in 12

About 1 in 12 people in the United

States (more than 26 million) have

asthma, and the numbers are

increasing every year.

12 Million

About 1 in 2 people (about 12

million in the United States) with

asthma had an asthma attack in

2013, but many asthma attacks

could have been prevented.

56 Billion

Asthma cost the U.S. about $56

billion in medical costs, lost school

and work days, and early deaths in

2013.

Asthma is a lifelong disease that causes

wheezing, breathlessness, chest tightness, and

coughing. It can limit a person’s quality of life,

but we do know that most people with asthma

can control their symptoms and prevent asthma

attacks by avoiding asthma triggers and correct-

ly using prescribed medicines, such as inhaled

corticosteroids.

TYPES OF ASTHMA

Asthma is considered a single disease in

which the airways are inflamed and narrowed.

However, there are several types of asthma

that reflect the triggers and the patient’s

genetic makeup that can cause an asthma

attack. Treatments may vary depending of the

type of asthma you have.

Exercise-Induced Asthma Exercise often causes asthma symptoms, and

the trigger is believed to be rapid breathing

and airway cooling associated with vigorous

exercise. Sports linked to exercise-induced

asthma involve continuous play, such as

basketball, soccer, and long-distance running,

and sports that take place in cold, dry air,

such as hockey or skiing. Treatment and mon-

itoring can allow people with exercise-induced

asthma to participate in the physical activity or

exercise of their choice.

Nocturnal/Nighttime AsthmaWorsening of asthma at night is common, and

is often linked to exposure to allergens in the

bedroom, such as dust mites; a delayed allergic

response; gastroesophageal reflux (a condition that

causes heartburn); a drop in body temperature that

cools the airways; medications wearing off, espe-

cially in early morning hours; and sleep apnea.

Allergic AsthmaAllergies are known to make asthma symptoms

worse. Among the most common allergies are to

animals, dust mites, mold, pollen, and foods. You

can adjust your lifestyle to avoid these allergens,

or be tested to confirm your allergies and get aller-

gy shots or medicines specific to allergic asthma.

Occupational AsthmaExposure to high concentrations of chemicals

or dust in the workplace can trigger an asthma

attack. To confirm occupational asthma, you

can compare the results of a peak flow test at

work and away from work. A peak flow test

measures how hard you can breathe out. If

confirmed, you will need to develop a plan to

limit your exposure to allergens in addition to

taking any medications prescribed.

Steroid-Resistant AsthmaAlthough corticosteroids are one of the most

common treatments for most people with

asthma, some people with severe asthma do

not respond to steroid treatment. If you are in

this category, you will need to work with your

doctor to develop an action plan for treatment.

Cough-Induced AsthmaMany people with asthma do not wheeze. In-

stead, they have a dry, non-productive cough

in which they do not expel any mucus. It is

common in children and usually worsens while

exercising or sleeping. Treatments involve the

use of inhalers, and it can take six to eight

weeks for symptoms to improve.

context of our evolving knowledge of this common but complex disease.

Health care experts around the world agree that asthma is a respiratory disease in which the airways of the lungs become inflamed and narrower, and produce extra mucus. It is a chronic disease, so it usually lasts for your life-time, and it cannot be cured. However, asthma can be controlled with medicine and changes in lifestyle. The most common symptoms of asthma are coughing, shortness of breath, chest tightness, and wheezing.

THE HISTORY OF ASTHMAThe earliest recorded reference to respiratory problems is from ancient China in 2600 BC. This health problem was first called “asthma” in 400 BC by the Greeks because the word means “short of breath.” Despite this long history, little was known about asthma until fairly recently. Some people, for instance, thought it was a psychosomatic illness, mean-ing it was thought to be a mental illness, not a physical problem.

The knowledge of asthma began to grow in the first half of the 1900s, but it was only in the 1960s that health care experts recognized asthma as an inflammatory disease, which means it causes swelling of the airways. In people with asthma, a combination of envi-ronmental triggers and genetic factors cause the lungs’ airways to become inflamed.

In the 1980s, researchers learned more about how the body reacts to environmental triggers, and that knowledge has expanded greatly in the last three decades.

ASTHMA TRIGGERSThere are many factors that can inflame a person’s airways. These asthma triggers vary from person to person, but the common

ones are allergies, respiratory infections, tobacco smoke, air pollution, cold air, pets, cockroaches, mold, dust mites, smoke from burning wood, physical exercise, and stress.

Less common triggers that create problems for people with asthma include medicines, such as some anti-inflammatory drugs and beta-blockers, and sulfites in food and drinks, such as wine.

Your genes also are a factor. If one parent has asthma, a child is 30 percent more likely to have asthma, and if both parents have asth-ma, a child is 70 percent more likely to have asthma. Also, if your family members have a tendency to develop allergies, you may be more likely to have allergies, and your airways are more likely to be inflamed by allergens. About half of all Americans are sensitive to at

It was only in the 1960s that health care experts recognized asthma as an inflammatory disease, which means it causes swelling of the airways.


PATIENT INFORMATION SERIES | ASTHMA TODAY

least one allergen that could trigger asthma.A representative of the U.S. National In-

stitute of Environmental Health reported on allergens in the average home during the ATS International Conference. He said that nearly half of the homes taking part in a recent study had at least six detectable allergens. Three out of four homes had at least one allergen. The study also found that if a person is sensitive

to one allergen, that person is likely to be sen-sitive to several similar allergens, which are called clusters. For example, if you are allergic to cats, you’re probably allergic to dogs, too.

Also during the conference, a researcher from the University of Tennessee Health Science Center reported on her research showing that newborns exposed to particles in the air, known scientifically as particulate

COMMON ASTHMA TRIGGERS



Many factors can cause an asthma attack. If

you have asthma, you need to be aware of

your triggers and avoid them.

Tobacco SmokeNo one with athma should

smoke or be exposed

to secondhand smoke.

Smoking risks for those

with asthma are particularly high. Secondhand

smoke is smoke created by a smoker and

inhaled by a second person, and it is a major

cause of asthma attacks.

Dust Mites Dust mites are tiny bugs

that are in almost every

home, and there are several

types of dust mites. They

are common in bedding and in older mat-

tresses and pillows, so use mattress covers

and pillow covers to create a barrier between

dust mites and yourself. Don’t use down-filled

pillows, quilts, or comforters. Remove stuffed

animals and clutter from your bedroom.

Outdoor Air PollutionAir pollution commonly

comes from factories and

cars. Follow air quality fore-

casts in newspapers, on

radio or television reports, and on the Internet,

and plan your activities for when air pollution

levels will be low.

CockroachesCockroach droppings often

are found in water and food

sources, and where food

crumbs accumulate. Keep

your home clean by sweeping and vacuuming

every two or three days and use roach traps or

gels to reduce the number of cockroaches.

PetsCat allergies are twice as

common as dog allergies.

Dogs and cats secrete

fluids and shed dander

containing allergens. If you have a furry pet,

vacuum often. If your floors have a hard

surface, such as wood or tile, clean them with

a damp mop every week. Bathe pets regularly

and keep them outside the bedroom.

MoldHigh humidity can lead to

mold. An air conditioner or

dehumidifier will help you

keep the humidity level low.

Use a hygrometer to check humidity levels

and keep them below 50 percent. Fix water

leaks, which let mold grow behind walls and

under floors.

Smoke from Burning WoodSmoke from burning wood

or plants contains harmful

gases and small particles,

so avoid burning wood in your home.

matter, often have long-term problems from those exposures, such as airway inflamma-tion, decreased lung growth and development of the immune system.

DIAGNOSIS OF ASTHMADiagnosing asthma is difficult because there is not one definitive medical test for it, and its symptoms can cause it to be confused with another lung disease—chronic obstructive pulmonary disease, or COPD. Asthma is a respiratory disease marked by spasms in the airways of the lungs. It is most often recog-nized in children, although about 30 percent of people are not diagnosed with asthma until they are adults. In contrast, COPD is a general medical term for people who have chronic bronchitis (brong-KII-tis), emphyse-ma (em-fuh-SEE-muh), or a combination of the two, and it usually is not diagnosed until age 40 or later.

If you suspect you have asthma, you will need to have a complete physical exam and a doctor or health care professional will need to ask several questions as part of your complete medical history:

Do you cough a lot, especially at night? Are your breathing problems worse after

physical activity or at certain times of year? Do you have chest tightness, wheezing, or

a cough that lasts more than 10 days? Do you have family members who have asth-

ma, allergies, or other breathing problems?Your physical exam is likely to include a

breathing test, called spirometry (spa-ROM-i-tree), that will assess the health of your lungs by measuring how much air you exhale after taking a deep breath, and how quickly you exhale. A second common test uses a peak flow meter to measure how hard you can breathe out.

Other tests used to diagnose asthma include:

Methacholine challenge: If your airways constrict after inhaling methacholine (meth-a-KOH-leen), you most likely have asthma. You can learn more about this test by reading another ATS Patient Informa-tion Series flier, “Lung Function Studies:

Methacholine or Challenge Test.”


ASTHMA CLASSIFICATIONS

Asthma is classified based on the severity of

symptoms and the results of lung function

tests before treatment. These symptoms

include difficulty breathing, wheezing, chest

tightness, and coughing. Over time, the classi-

fication of your asthma may change.

Mild Intermittent AsthmaAsthma is considered mild intermittent if,

without treatment, all of the following are true:

Symptoms occur fewer than two days a

week

Attacks do not interfere with normal activities

Nighttime symptoms occur fewer than two

days a month

Spirometry and peak flow lung function

tests are normal when the person is not

having an asthma attack

Mild Persistent AsthmaAsthma is considered mild persistent if, with-

out treatment, any of the following are true:

Symptoms occur more than two days a

week but do not occur every day

Attacks interfere with daily activities

Nighttime symptoms occur three to four

times a month


tests are normal when the person is not

having an asthma attack

Moderate Persistent AsthmaAsthma is considered moderate persistent if,

without treatment, any of the following are true:

Symptoms occur daily; inhaled, short-

acting asthma medication is used every day

Symptoms interfere with daily activities

Nighttime symptoms occur more than one

time a week, but do not happen every day


tests are abnormal

Severe Persistent AsthmaAsthma is considered severe persistent if,

without treatment, any of these are true:

Symptoms occur throughout each day

Symptoms severely limit daily physical

activities

Nighttime symptoms occur often, some-

times every night


tests are abnormal

Exhaled nitric oxide test: When your air-ways are inflamed, your breath may have high levels of the gas nitric oxide, which may be a sign you have asthma.

Allergy testing: Skin tests and blood tests can be used to determine allergies to pets, dust, mold, and pollen, all of which are asthma triggers, and confirm a diagnosis of allergic asthma.

Eosinophil levels: Eosinophils (ee-oh-SIN-oh-phils) are a type of white blood cell. If you have elevated levels of eosin-ophils, they can trigger an inflammatory response. Eosinophils can be measured in your blood or your sputum, which is the mucus you discharge when you cough.

ASTHMA MEDICINESAsthma is a chronic disease that has no cure, but there are two types of treatments to con-trol it—maintenance and rescue medicines. Maintenance medicines are taken regularly to control asthma symptoms. Rescue medicines are used when you need quick relief during an asthma attack.

Most people who have asthma need to take long-term maintenance medicines that reduce airway inflammation and prevent the start of more severe asthma symptoms. These medicines do not give you quick relief when you are having an asthma attack.

The most common maintenance medi-cines are inhaled corticosteroids (KAWR-tuh-koh-STER-oid). These non-habit-forming drugs are different from illegal muscle-build-ing steroids taken by some athletes. Other long-term medicines to control asthma include leukotriene (LU-koh-tri-EEN) mod-ifiers and long-acting beta agonists (BAY-ta-AG-a-nists). Occasionally, a long-acting anticholinergic (An-tee-KOH-luh-nur-jik) or theophylline (THEE-a-fill-een) is used. Other maintenance medicines are shots that can be administered in your physician’s office. Certain types of medicines and combinations of medicines for asthma are thought to be more effective, and new medicines are being studied in clinical trials.

When rescue medicines are needed, the most commonly used are the short-acting

beta2 agonists, such as albuterol (al-BYOO-ter-ol), which relax the tight muscles around your airways to open them up so air can flow through them. Another common rescue med-icine is ipratropium (IP-ra-TROH-pee-um).

Be sure to follow your doctor’s instruc-tions for taking your medicine to keep your asthma under control and to avoid an asthma attack. (See Asthma Action Plan on page 5.)

INHALERS AND NEBULIZERSThe most effective way to take asthma medi-cines is to breathe them in through the mouth so they can travel through your airways to your lungs. This is done using one of two devices—an inhaler or a nebulizer.

Inhalers are used most often because they are small and easy to carry. It is important to

use your inhaler correctly. Many people do not use their inhalers correctly, so they do not get the full benefit of the medicine. In fact, a study published in the medical journal Asthma in 2011 found that only 2 percent of people with severe asthma adhere to their medication schedules and use their inhalers correctly. Be sure to ask your doctor or health care professional to show you how to use an inhaler. For those who have trouble using an inhaler correctly, attaching a spacer or hold-ing chamber can make it easier to use.

The most common type of inhaler is a me-tered-dose inhaler (MDI), which is pressur-ized so it releases a fixed amount of medicine. It is best to use an MDI that has a dose count-er that shows how much medicine is left in it. For MDIs without a dose counter, you will need to know how many puffs your inhaler holds and how many puffs you take each


day so that you know how many days your inhaler will last. You cannot tell how much medicine is left in an inhaler by shaking it. Relying on shaking your inhaler could result in not having medicine at a critical time. You can learn more about MDIs by reading another ATS Patient Information Series flier, “Using your Metered Dose Inhaler (MDI).”

A second type of inhaler is a dry powder

inhaler in which the user inhales medicine saved in the form of a dry powder.

A new type of inhaler that could improve asthma treatments, an extrafine-particle inhal-er, was discussed during the ATS International Conference. The lungs contain airways of var-ious sizes. Evidence is growing that a group of people have “small airway asthma,” and disease in these small airways is difficult to detect, so it has been called “the silent zone.” Traditional asthma inhalers contain particles of medicine that are larger than 2 microns. These larger particles of medicine can only reach large and medium airways, not the small airways, espe-cially the airways near the edges of the lung.

However, inhalers using particles smaller than 2 microns can more effectively reach the small airways and airways near the edges of the lung. Preliminary evidence from studies of extrafine-particle inhalers shows that they not only are better at controlling asthma in all patients, they are more cost-effective. More

A list of triggers that may cause an

asthma attack

A list of your medicines

An asthma action plan is divided into three

zones—green, yellow, and red.

The green zone is where you want to be daily

because you have no asthma symptoms and

you feel good. Continue to take your long-

term maintenance medicines even if you’re

feeling well.

The yellow zone means that you are

experiencing asthma symptoms, so you

should use your rescue medicine to keep your

asthma from getting worse.

The red zone means you are experiencing

severe asthma symptoms or an asthma

attack. Follow the steps of your asthma action

plan and get immediate medical treatment if

your symptoms do not improve.


Asthma is a chronic disease that requires

you to actively monitor and maintain

your health. It is wise to work with your

health care provider to develop an asthma

action plan that is a written, personalized

worksheet that shows you the steps to take

to prevent your asthma from getting worse.

The plan should have specific instructions

for early treatment of asthma symptoms

and provide guidance on when to call

your health care provider or when to go to

the emergency room. You can download

an action plan from the U.S. National

Institutes of Health at https://www.nhlbi.

nih.gov/files/docs/public/lung/asthma_

actplan.pdf. Your asthma action plan

should include:

Your name

Emergency contact information

Contact information for your health

care provider

Your asthma severity classification

ASTHMA ACTION PLAN

studies of these extrafine-particle inhalers are needed to confirm that they truly are more ef-fective than coarse-particle inhalers, according to researchers.

Another way to take asthma medicines is with a nebulizer. A nebulizer is a device that converts liquid medicine into a fine mist you inhale by breathing through a mouthpiece or mask.

NEW ASTHMA RESEARCHThe ATS International Conference featured several presentations of research that is prom-ising, but that may be years away from being accepted and used to better treat people with asthma. These presentations included debates that not only highlighted new approaches to diagnosing and treating asthma, but concerns about them, too.

One lecture focused on molecular phenotyping (FEE-noh-type-ing), which breaks down asthma into different categories based on how a person’s genes interact with their environment. The goal is to provide treatment tailored to this gene-environment interaction. This approach is sometimes


A nebulizer is a device that converts liquid medicine into a fine mist you inhale by breathing through a

mouthpiece or mask.

may play a major role in inflaming the air-ways of a person in one subtype, while those factors may not be as important for a person in a different subtype.

Genomics—the science of genes—is expected to provide clues about each person’s subtype so we know how to alter lifestyles and which medicines work best. One such type of medicine is biologics, which is a medi-cine developed through biological processes using living cells or organisms rather than the chemicals used in traditional medicines. Although expensive, biologics are increas-ingly being used to treat a variety of medical conditions, such as cancers, cardiovascular disease, diabetes, and autoimmune diseases, such as rheumatoid arthritis and psoriasis. More than 900 biologics are being developed, and 21 of those are being developed to treat patients with asthma and other lung diseases. The first biologics for asthma are most likely to benefit patients with severe asthma and to complement standard therapies at times when a patient’s asthma is not well controlled.

To date, only one biologic for asthma, omalizumab (OH-ma-LIZ-oo-mab), has been approved by the U.S. Food and Drug Administration (FDA). It is used for severe, persistent allergic asthma that is not con-trolled by inhaled corticosteroids. The FDA is considering another biologic, mepolizumab, for approval for maintenance treatment for patients with severe eosinophilic asthma. A

third biologic, lebrikizumab (LEB-rick-is-u-mab), is being studied in clinical trials to reduce airway inflammation.

Another treatment that has created a great deal of discussion is bronchial thermoplasty. As with other medical treatments, bronchial thermoplasty will continue to be studied by researchers as to its benefits, harms, and long-term consequences. In the interim, this treat-ment is only intended for adult patients with severe asthma within a research environment, such as part of a clinical study or an institu-tional review board-approved independent systematic registry.

LOOKING AHEADAsthma is a disease that affects 300 million people around the world, and experts predict that another 100 million people could be diagnosed with asthma in the next 10 years. Evidence suggests that asthma’s growing prev-alence is due to increased urbanization and the adoption of a “Western” lifestyle. Despite the gloomy statistics, researchers are making amazing advances in the diagnosis and treat-ment of all types of asthma.

If you suspect you have asthma, be sure to consult a doctor. If you do have asthma, re-member that it is a chronic disease that while it cannot be cured, it can be controlled. The key to control is to follow recommendations from health care professionals concerning your lifestyle and to take all medicines as directed. An Asthma Action Plan can help you do this. Research suggests that many people who struggle to control their asthma are not taking their medicines as prescribed. Shockingly, one study found that only 2 percent of people with severe asthma follow their doctor’s orders about when to take their medicines and use their inhalers correctly. The U.S. Centers for Disease Control has a video demonstrating how to use an inhaler.

To stay informed about the latest recom-mendations and developments about asthma, you can visit the American Thoracic Society Web page about asthma, which contains several resources for patients with asthma. Also, mark Oct. 4-10, 2015, on your calendar to take part in Asthma Week at ATS.

LOOK FOR ASTHMA WEEK AT ATS OCTOBER 4-10

To learn more about the latest advances

in asthma research and treatments, mark

your calendar for October 4-10, 2015, and

bookmark Lung Disease Week at the ATS

in your Web browser.

Throughout the week, asthma experts with

the American Thoracic Society (ATS) will

provide a variety of information for patients

developed with an ATS Public Advisory

Roundtable partner, the Asthma and

Allergy Foundation of America.

The information on the website will include

links to asthma information from ATS pub-

lications, the ATS International Conference,

and ATS educational sessions. Also, tune in

for a live webinar presented by an asthma

health care professional.

PLEASE TAKE A SHORT SURVEY ABOUT ASTHMA TODAY: www.surveymonkey.com/r/patientresource 6


called personalized medicine. Traditionally, the same medicines have been used to treat everyone with asthma. This new approach of categorizing subtypes of asthma looks for bio-markers to identify each subtype. Currently, four subtypes have been identified, ranging from mild to very severe asthma. In theory, corticosteroids may not work best for each subtype. Also, obesity, smoking, or infections

A peak flow test measures how hard you can breathe out. It is a common test used in all types of asthma.

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American Thoracic Society PATIENT INFORMATION SERIES ...medsocietiesforclimatehealth.org/wp-content/... · Asthma is a lifelong disease that causes wheezing, breathlessness, chest